الرحمن الله بـسمالرحيم

ORAL MEDICINE DEPARTMENTPIGMENTED LESIONS OF THE ORAL

MUCOSA SEMINARDONE BY

DR.ATHAR THAIRSUPERVISED BY

DR.YASSER AKRAM

PIGMENTED LESIONS OF THE ORAL

MUCOSA

Blue, brown and black discoloration constitute the pigmented lesions of the oral mucosa, these lesions represent a variety of

clinical entities, ranging from-:1-physiological changes (e.g. racial pigmentation ).

2-manifestations of systemic illnesses (e.g. Addison's disease).3-Malignant neoplasm (e.g. melanoma and Kaposi sarcoma)4-Exogenous pigmentation is commonly due to foreign-body

implantation in the oral mucosa.5-Endogenous pigments include melanin, hemoglobin,

hemosiderin and carotene.

Differential Diagnosis of Oral Pigmented LesionEvaluation of the patient presenting with pigmented lesion should

include-:

1-full medical and dental history, the history should include the onset and duration of the lesion, the presence of associated skin hyperpigmentation the presence of systemic signs and symptoms ( e.g malaise, fatigue, weight loss) and smoking habits.

2-Extra oral and intra oral examinations. pigmented lesions on the face, perioral skin and lip should be noted. the number, distribution, size, shape and colour of intraoral pigmented lesions should be assessed.

3-Investigations such as discopy test, radiography, biopsy and laboratory investigations such as blood test can be used to confirm a clinical impression and reach a definitive diagnosis.

Pigmented lesions are classified into-:▼ BLUE/PURPLE VASCULAR LESIONS.

the lesion may harbor vessels close to the overlying epithelium and appear reddish blue or, if a little deeper in the connective tissue, a deep blue. Angiomatous lesions occurring within muscle (so-called

intramuscular hemangiomas) may fail to show any surface discoloration .

Clinicaly: Whereas most hemangiomas are raised and nodular, some may be flat, macular, and diffuse, particularly on the facial skin, where they are referred to as port-wine stains

Hemangioma Vascular lesions presenting as proliferations of vascular channels are tumorlike hamartomas

TREATMENT:-Since most hemangiomas spontaneously involute during teenage years Patient who require treatment can undergo conventional surgery, laser surgery, or cryosurgery. Larger lesions that extend into muscles are more difficult to eradicate surgically, and scleroting agents such as 1% tetradecyl sulfate may be treated by intralesional injection

Varix *pathologic dilatations of veins or venules are varices or varicosities,

*the chief site of such involvement in the oral tissues is the ventral tongue

*Clinicaly:Lingual varicosities appear as tortuous serpentine blue, red, and purple elevations that course over the ventrolateral surface

of the tongue, with extension anteriorly .

*They are painless and are not subject to rupture and hemorrhage

*some can be blanched, others are not, due to the formation of intravascular thrombi .

The varix resembles the hemangioma both clinically and histologically, yet it is distinguished by two features: (1) the patient’s age at its onset and (2) its etiology.

Hereditary Hemorrhagic Telangiectasia Characterized by multiple round or oval purple papules measuring less than 0.5 cm in diameter, hereditary hemorrhagic telangiectasia (HHT) is a genetically transmitted disease, inherited as an autosomal dominant trait

There may be more than100 such purple papules on the vermilion and mucosal surfaces of the lips as well as on the tongue and buccal mucosa. the facial skin and neck are also involved. Examination of the nasal mucosa will reveal similar lesions, and a past history of epistaxis may be a complaint. Indeed, deaths have been reported in HHT attributable to epistaxis

Differential diagnosis should include petechial hemorrhages with an attending platelet disorder, petechiae are macular rather than papular and (as foci of erythrocyte extravasation with breakdown to hemosiderin) red or brown rather than purple

There is no treatment for the disease. If the patient would like to have the telangiectatic areas removed for cosmetic reasons, the papules can be cauterized by electrocautery in a staged series of procedures using local anesthesia

Microscopically:- HHT shows numerous dilated vascular channels with some degree of erythrocyte extravasation around the dilated vessels.

▼ BROWN MELANOTIC LESIONSEphelis and Oral Melanotic Macule The common cutaneous freckle, or ephelis represents an increase in melanin pigment synthesis by basal-layer melanocytes

Ephelides can be encountered on the vermilion border of the lips, with the lower lip being the favored site since it tends to receive more solar exposure than the upper lip. The lesion is macular and ranges from being quite small to over a centimeter in

diameter. Some patients report a prior episode of trauma to the area .

The intraoral counterpart to the ephelis is the oral melanotic macule. These lesions are oval or irregular in outline, are brown or even black, and tend to occur on the gingiva,

palate, and buccal mucosa.

Microscopically,a normal epithelial layer is seen, and the basal cells contain numerous melanin pigment granules without proliferation of melanocytes

The oral melanotic macule does not represent a melanocytic proliferation, and does not predispose to melanoma. Once it is removed, no further surgery is required.

Malignant Melanoma Oral mucosal melanomas are extremely rare. Their prevalence appears to be higher among Japanese people than among other populations. Melanomas arising in the oral mucosa tend to occur on the anterior labial gingiva and the anterior aspect of the hard palate.

clinically oral melanomas are macular brown and black plaques with an irregular outline. They may be focal or diffuse and mosaic

Eventually, melanomas become more diffuse, nodular with foci of hyper and hypopigmentation.

Teratment:- Excision with wide margins is the treatment of choice this may be difficult to accomplished because of the anatomical constrains and proximity to the viral

structures. radiation and chemotherapy are ineffective which adds to the difficulty associated with the management of this malignancy, the prognosis for patients

with oral melanoma is much worse than that for patients with cutaneous lesions and the overall 5-years survival rate is 15%.

Physiologic (racial ) Pigmentation Black people, Asians, and dark-skinned Caucasians frequently show diffuse

melanosis of the facial gingiva. In addition, the lingual gingiva and tongue may exhibit multiple, diffuse, and reticulated brown macules. Although other causes of

hyperpigmentation are possible, racial pigmentation, representing basilar melanosis, evolves in childhood and usually does not arise de novo in the adult.

Therefore, any multifocal or diffuse pigmentation of recent onset should be investigated further to rule out endocrinopathic disease

Peutz-Jeghers Syndrome In Peutz-Jeghers syndrome oral pigmentation is distinctive and is usually pathognomonic. Multiple focal melanotic brown macules are concentrated about the lips while the remaining facial skin is less strikingly involved. The macules appear as freckles or ephelides usually measuring < 0.5 cm in diameter. Similar lesions may occur on the anterior tongue, buccal mucosa, and mucosal surface of the lips. Ephelides are also seen on the fingers and hands

Histologically, these lesions show basilar melanogenesis without melanocytic proliferation.

▼ BROWN HEME-ASSOCIATEDLESIONSEcchymosis Traumatic ecchymosis is common on the lips and face yet is uncommon in the oral mucosa. Immediately following the traumatic event, erythrocyte extravasation into the submucosa will appear as a bright red macule or as a swelling if a hematoma forms. The lesion will assume a brown coloration within a few days, after the hemoglobin is degraded to hemosiderin.

*Certainly, patients taking anticoagulant drugs may present with oral ecchymosis, particularly on the cheek or tongue, either of which can be traumatized while chewing. Coagulopathic ecchymosis of the skin and oral mucosa may also be encountered in hereditary coagulopathic disorders and in chronic liver failure

Petechia Capillary hemorrhages will appear red initially and turn brown in a few days once the extravasated red cells have lysed and have been degraded to hemosiderin.

Petechiae secondary to platelet deficiencies or aggregation disorders are usually not limited to the oral mucosa but occur concomitantly on skin

oral petechiae are usually confined to the soft palate, where 10 to 30 petechial lesions may be seen and can be attributed to suction. Excessive suction of the soft palate against the posterior tongue is self inflicted by many patients who have a pruritic palate at the onset of a viral or an allergic pharyngitis; they simply “click” their palate. When traumatic or suction petechiae are suspected, the patient should be instructed to cease whatever activity may be contributing to the presence of the lesions. By 2 weeks, the lesions should have disappeared. Failure to do so should arouse suspicion of a hemorrhagic diathesis, and a platelet count and platelet aggregation studies must be ordered.

▼ GRAY/BLACK PIGMENTATIONSAmalgam Tattoo By far, the most common source of solitary or focal pigmentation in the oral mucosa is the amalgam tattoo.

*No signs of inflammation are present at the periphery of the lesion. In some cases especially when the amalgam particles are large enough they can be seen in intraoral radiographs as fine radiopaque granules.

Hairy Tongue Hairy tongue is a relatively common condition of unknown etiology. The lesion involves the dorsum, particularly the middle and posterior one-third. Rarely are children affected. The papillae are elongated, sometimes markedly so, and have the appearance of hairs.

Microscopically, the filiform papillae are extremely elongated and hyperplastic with keratosis. External colonization of the papillae by basophilic microbial colonies is a prominent feature

Treatment consists of having the patient brush the tongue and avoid tea and coffee for a few weeks. Since the cause is undetermined, the condition can recur.